The state of health

Published: Monday, 14 December 2015

Martin Hodgson looks at the CQC annual report on the state of health.


  • The latest report by the Care Quality Commission shows that almost 60% of adult social care services are rated as providing good or outstanding care.
  • 7% of services are rated inadequate, some with inadequate staffing and poor medicines management.
  • Inspectors note many examples of good practice but conclude that there is 'room for improvement' across the sector.
  • In general, nursing homes were rated lower for quality of care than other adult social care services, with just under half (46%) rated good or outstanding and one in 10 (10%) rated inadequate.

The Care Quality Commission has published its latest annual overview report, The state of health care and adult social care in England 2014/15.

The report states that for the first time in its annual reports, the CQC has had access to a full range of consistent quality data on which to base conclusions about how health and care services are performing.

The data it refers to is derived from the new CQC inspection and rating system, which has been introduced for all regulated health and social care services over the past year. The system has involved CQC inspectors applying a new five key question test to determine ratings for each service. These have then been published on the CQC website. Services are rated as outstanding, good, requires improvement or inadequate.

The annual report summarises and analyses the ratings for each service type – for example for adult social care, acute healthcare and primary care – and picks out trends and patterns.

Trends in adult social care

The CQC report states that all of the services rated over the past year have been subjected to intense pressures, not only from tighter budgets and financial pressures, but also from the 'ageing' population, which means that more older people in society require support. The CQC says that the adult social care market is responding to this challenging environment in a number of ways. For instance, the CQC reports that registration data shows a decrease in the number of smaller residential homes but an increase in the average number of beds. It concludes that some mid-sized services are closing while new, larger services expand. This reflects an 'economies of scale' approach by providers.

The CQC also reports a 42% increase in the number of domiciliary care agencies during the last year.

Adult social care ratings

Up to 31 May 2015, the cut-off point for this report, CQC states that it had inspected and rated almost a fifth (17%) of adult social care services. This included 212 community social care services, 675 domiciliary care agencies, 2,211 residential homes and 1,275 nursing homes.

Of the services inspected, overall ratings showed:

  • Almost three in five (59%) received a 'good' or 'outstanding' rating overall, including 67% of the domiciliary care agencies and 64% of the residential care homes.
  • Around a third (33%) of services were rated as 'requires improvement'.
  • 7% of services were rated 'inadequate'.

The data for specific key questions showed:

  • More than four in five (85%) of services were rated 'good' or 'outstanding' for caring.
  • 10% were rated inadequate for safety.
  • 8% of services were rated inadequate for the well-led key question.

In general, nursing homes were rated lower for quality of care than other adult social care services, with just under half (46%) rated good or outstanding and one in 10 (10%) rated inadequate.

The CQC noted examples of exemplary good practice but concludes that there is 'room for improvement' across the whole of the adult social care sector. The CQC also reflects on the effectiveness of the new inspection regime. Despite it being early in its implementation cycle, inspectors report that re-inspections carried out so far have led to 40% of inadequate ratings at service level changing to a higher rating.

Inspectors have also moved to stop the provision of poor, dangerous care, in 2014–15 issuing 937 warning notices to providers, telling them they needed to make urgent improvements.

Specific concerns

The CQC analysis notes specific concerns about safety and leadership.

The report notes that providers were most likely to get an 'inadequate' rating for the key question on safety. While 57% of adult social care services were rated good or outstanding for safety, 33% were rated as 'requires improvement' and 10% were rated inadequate.

Issues included:

  • inappropriate numbers of staff on duty
  • not appropriately recognising and recording incidents as safeguarding issues
  • poor follow-up and learning after accidents and incidents
  • lack of knowledge about risk management
  • medicines not administered properly
  • 'smelly' or 'dirty' premises.

The report also states that 31% of services 'required improvement' in terms of leadership and 8% were rated as inadequate.

According to the CQC data, the quality of leadership most closely correlates with the overall quality of a service. CQC interprets this as showing that having a consistent and effective registered manager in post has a positive influence on the quality of a service and helps to make sure that people receive care services that are safe, effective, caring and responsive. The report notes that the 'outstanding leaders' recognised by inspectors are characterised by their 'passion, excellence and integrity, collaboration with their staff and the provider, and their determination to ensure people's views and wishes are at the centre of their care.'

Significant challenges

The report not only reviews the state of current services, but also attempts to look ahead. It points out that, during the last two decades, the challenges facing the adult social care sector have not been exposed to the same public and political debate as health care. The CQC concludes that there is currently no 'widely shared vision' for how the sector should change and adapt.

The CQC states that, in order to survive and thrive in the future, services will require 'resilience, innovation and creativity' supported by 'great leadership'. It raises concerns that many services 'do not yet have the leadership and culture required' to deliver safe, high-quality care.

The regulator therefore urges services to:

  • build a 'collaborative culture' that reaches out to people who use services
  • be 'open and transparent', learning from mistakes and ensuring information and data are to hand to make good decision
  • ensure that services have the right 'staff and skill mix' in place to ensure that care is always safe.

The report states that the sector must continue to improve and adapt as, during the remainder of 2015–16 and beyond, providers will face an 'even more difficult' operating environment.

Further information

The full report, The state of health care and adult social care in England 2014/15, October 2015, CQC, can be downloaded from the CQC website at:

About the author

Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.

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